Payment of Gratuity Act, 1972

FORM 'F'
See sub-rule (1) of Rule 6
Nomination
To,
«business_name»
#A2, 4th Floor, Cnergy IT Park,
Old Standard Mill Compound,
Appasaheb Marathe Marg,
Prabhadevi, Mumbai, Maharashtra 400025

1. Shri/Shrimati/Kumar (Employee Name )

whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity
payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become
payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion
indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (h) of Section
2 of the Payment of Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.

4 (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the

to the controlling authority in terms of the proviso to clause (h) of Section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Name in full with full Relationship Age of Proportion by which

address of nominee(s) with the nomine the gratuity will be
employee e shared
(1) (2) (3) (4)
 Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. Post held with Ticket No.or employee Code. if any
7. Date of appointment
8. Permanent address:

Place:
Signature/Thumb-impression of the
Employee
Date:

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

Place:
Date:
 Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised
Designation

Date: Name and address of the establishment or

rubber stamp thereof.

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.
Date: Signature of the Employee
Note.—Strike out the words/paragraphs not applicable.
 (FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds and Employees Pension
Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the
Employees Pension Scheme 1995)

1. Name (IN BLOCK LETTERS) :

2. Date of Birth : 3. Account No.

4. *Sex : MALE/FEMALE: _ 5. Marital Status : _

6. Address Permanent / Temporary :

PART – A (EPF)

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s)
mentioned below to receive the amount standing to my credit in the Employees Provident Fund, in the event of
my death.
If the nominee is
Name of Addre Nominee’s Date Total amount or minor name and
the ss relationship of share of address of the
Nominee with the Birth accumulations in guardian who may
(s) member Provident Funds to receive the amount
be paid to each during the minority
nominee of the nominee
1 2 3 4 5 6

1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund Scheme 1952 and
should I acquire a family hereafter the above nomination should be deemed as cancelled.
2. * Certified that my father/mother is/are dependent upon me.

Strike out whichever is not applicable Signature/or thumb impression of the

subscriber
 PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/Children
Pension in the event of my premature death in service.

Sr. Name & Address of the Family Age Relationship with the
No Member member
(1) (2) (3) (4)

Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I
acquire a family hereafter I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) &
(ii) in the event of my death without leaving any eligible family member for receiving pension.

Name and Date of Birth Relationship with member

Address of
the nominee

Date

Signature or thumb impression of the

subscriber
 CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri
/ Smt./ Miss employed in my establishment after he/she has
read the entries / the entries have been read over to him/her by me and got confirmed by him/her.

Date : Signature of the employer or other authorised

officer of the establishment

Name & address of the Factory /Establishment Place : :

Date: :
 New Form : 11 - Declaration Form
(To be retained by the employer for future
reference)
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up Employment in any Establishment on which EPF Scheme, 1952
and for EPS, 1995 is applicable)

1. Name of Member (Aadhar Name)

2. «lblfatherorhusbundname»

3. Date of Birth (dd/mm/yyyy)

4. Gender (Male / Female / Transgender)
5. Marital Status ?
(Single/Married/Widow/Widower/Divorcee)
(a) eMail ID
6. (b) Mobile No (Aadhar Registered)
Whether earlier member of the Employee's
7. Provident FundScheme, 1952 ?
Whether earlier member of the Employee's
8. PensionScheme, 1995 ?
Previous Employment details ? (If Yes, 7 & 8 details
above)
a) Universal Account Number (UAN)
9.
b) Previous PF Account Number
c) Date of Exit from previous Employment ?
(dd/mm/yyyy)
d) Scheme Certificate No (If issued)
e) Pension Payment Order (PPO) (If issued)
a) International Worker Yes / No
b) If Yes, state country of origin (name of other
10. country)
c) Passport No.
d) Validity of passport (dd/mm/yyyy) to
(dd/mm/yyyy)
KYC Details : (attach self attested copies of Must Enclose Scan copy for the following documents
following KYC's)
11.
a) Bank Account No. & IFS Code
b) AADHAR Number
c) Permanent Account Number (PAN), If available

First EPF First Are you EPF If Yes, EPF If Yes, EPS After Sep 2014
(Pension) earned EPS
12. Member Employ Member Amount
Amount (Pension)
Enrolled ment before Withdraw
Amount
Date EPF 01/09/2014 n? Withdrawn?
Withdrawn before
Wages Join current
Employer?
 UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge
2) I authorise EPFO to use my Aadhar for verification / authentication / eKYC purpose for service delivery
3) Kindly transfer the fund and service details, if applicable, from the previous PF account as declared above to
the present PF account.
(The transfer would be possible only if the identified KYC details approved by previous employer has been
verified by present employer using his Digital Signature 4) In case of changes in above details, the
same will be intimated to employer at the earliest.

Date:
Place: Signature of Member

DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs. ……………..…………………….. Has joined on ……………………….and has
been alloted PF Number ……….……..
B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995: ((Post
allotment of UAN) The UAN alloted or the member is) Please Tick the Appropriate
Option : The KYC details of the above member in the JAN database
Have not been uploaded Have been uploaded but not approved Have been uploaded and approved
with DSC
C. In case the person was earlier a member of EPF Scheme, 1952 and EPS 1995;
The KYC details of the above member in the UAN database have been approved with Digital
Signature Certificate and transfer request has been generated on portal
As the DSC of establishment are not registered with EPFO, the member has been informed to file physical
claim (Form-13) for transfer of funds from his previous establishment.

Date: Signature of Employer with Seal of Establishment

 BACKGROUND VERIFICATION FORM

Please fill in the details with utmost attention, as these shall be verified by «Image:PhotoFil
the Company and/or by its authorised representatives. eName»

All details are compulsory.

Note: Please attach Resume & PP size photographs (Mandatory *)

PERSONAL DETAILS (ALL DETAILS ARE MANDATORY)

Name of Applicant:

Date of Birth (dd/mm/yy): Place of Birth:

Nationality:
Sex:
Father’s Name: Passport No.:

National ID: E-mail Address:

Home Phone: Office Phone: Mobile:

RESIDENTIAL ADDRESSES

PERMANENT ADDRESS:

Landmark:

City: State: Pin Code: Phone No.:

Duration of Stay: From (mm/yy) To (mm/yy) Nature of location: Rented Own Other (Specify)

CURRENT ADDRESS:

Landmark:

City: State: Pin Code: Phone No.:

Duration of Stay: From (mm/yy) To (mm/yy) Nature of location: Rented Own Other (Specify)
 Education Details

Qualification Name & Name & Course attended Marks Dates attended Roll
address of address of (%) number/
school/ (morning/ CGPA registration
college/ Year of Year number/
Board/ evening/ enrolment passed
institute university correspondence) & exam seat
(mm/yy) (mm/yy) number
Class
To which
the school/
college/
institute

Is
affiliated
to
Employment Record: Starting with your present or most recent employer, please list last 2 employments. When listing
consulting or temporary assignments, under “Employer”, state the name of the consulting or temporary agency that placed you
at the client site. Complete and accurate dates (month/year) must be provided.

EMPLOYER 1 (Last/Previous): Employee Id: From To (DD/MM/YY)::

(DD/MM/YY):

Street Address: Employer’s Remuneration/Salary:

Phone No.:

City: State: Country: Postal Code:

Job Title: Reason for leaving:

Supervisor’s Details:
Employment Status: (Please check the relevant box)

Name:
Title:
Full Time
Phone No.:
Contract /Through Outsourcing Agency

E-mail id:

Outsourcing Agency Details: (Preferably official)

Name:
HR Manager’s Details:

Address:
Name:
Description of Duties: Phone No.:

Tel No.:
E-mail id:
(Preferably official)

Current Employment Authority Provided

Yes/No
If No When
EMPLOYER 2 (Last to Last/Previous to From (DD/MM/YY):: To (DD/MM/YY)::
Employee Id:
Previous):

Street Address: Employer’s Remuneration/Salary:

Phone No.:

City: State: Country: Postal Code:

Job Title: Reason for leaving:

Supervisor’s Details:
Employment Status: (Please check the
relevant box)
Name:
Title:

Full Time
Phone No.:
Contract /Through Outsourcing
Agency E-mail id:

(Preferably
official)
Outsourcing Agency Details:

HR Manager’s Details:
Name:

Address: Name:
Description of Duties: Phone No.:

Tel No.: E-mail id:

(Preferably official)

Professional References

Relationship with
Name Contact No. Company Designation
the referee
1.
2.
 DECLARATION & AUTHORISATION

- I certify that the statements made in this application are true and complete to the best of my knowledge and belief. I
understand that false or misleading information may result in termination of the agreement.
· If upon investigations, any of the information furnished by myself is found to be incomplete, inaccurate or misleading,
I understand and agree that agreement can be revoked or terminated at any time during my employment.
· I hereby authorize the Company and/or any of its subsidiaries or affiliates and any persons, representatives or
organisations acting on its behalf (______________________), to verify the information presented for employment –
CV/ application/ forms/ documents, information available on internet or open source/ public domains and a social media
check to procure a background verification report or consumer report for that purpose.
· I hereby grant authority for the bearer of this document to access or be provided with full details of my previous
records.
· I hereby release and keep the Company, its representatives, employees, agents and Directors absolved from any
liability in relation to the declarations and information obtained by the Company and furnished myself as part of my
employment.
· I am aware and I will ensure, that neither myself or my family members, no Money/fee/postage/ gift to be paid or
given in goodwill to any one during the process of verification.
· I am aware that during the physical Address verification, there would be no photographs or documents to be shared
with verifier through any medium (WhatsApp, Email, Etc.).

I have read, understood, and hereby provide my acceptance and apply my signature consent to these statements.

Signature:
Date:
Name (In Block Letters :)

Documents Required (Compulsory) Attached Yes/ No

Completed & Signed Application Form
Copy of Relevant Employment Certificates
Copy of Passport
One Passport Size Photograph
Copy of Utility Bill of the Mentioned Address